ADVANCES IN LAPAROSCOPIC COLORECTAL SURGERY USING HARMONIC TECHNOLOGY CHARLES E. SCHMIDT COLLEGE OF SCIENCE BOCA RATON, FL April 23, :00:08

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1 ADVANCES IN LAPAROSCOPIC COLORECTAL SURGERY USING HARMONIC TECHNOLOGY CHARLES E. SCHMIDT COLLEGE OF SCIENCE BOCA RATON, FL April 23, :00:08 ANNOUNCER: The program is sponsored by Ethicon Endo-Surgery Inc. Over the next hour, see an expert clinical discussion of advances in technology and enhanced techniques in laparascopic colectomy live from the Charles E. Schmidt College of Biomedical Science at Florida Atlantic University in Boca Raton, Florida. During the program, surgeons Dr. Eduardo Parra-Davila, Dr. Gustavo Plasencia, and Dr. Moises Jacobs will demonstrate techniques and energy sources used in minimally invasive laparoscopic colectomy, resection, and mobilization of the rectum. The webcast will feature the use of Harmonic technology for laparoscopic colorectal surgery. OR-Live makes it easy for you to learn more. Just click on the "Request Information" button on your webcast screen and open the door to informed medical care. 00:01:14 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: Good evening, everybody. I want to welcome our audience to this live webcast for the advances in laparoscopic colorectal surgery using Harmonic technology. We're transmitting live from Boca Raton, Florida, from the institution of the Florida Atlantic University. I'm Eduardo Parra-Davila, I'm a colorectal surgeon. I'm program director of minimally invasive program at Boca Raton Community Hospital. And I'm delightful to have two great professional surgeons with me, Dr. Gustavo Plasencia to my left. 00:01:53 GUSTAVO PLASENCIA, MD, FACS: Good evening. 00:01:54 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: To the right corner, Dr. Moises Jacobs. Both are co-directors in minimally invasive surgery at Mercy Hospital and -- in Miami, Florida. I want to welcome you both and thank you very much for being with us. 00:02:06 GUSTAVO PLASENCIA, MD, FACS: Thank you, thank you very much. 00:02:09 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: Let's get into the program. First of all, we're going to -- there's a regular disclaimer that is -- that we need to present. Let's go for that first. Our topic today is mainly going to be the use of Harmonic technology in the colon surgery. And as we now, we started with benign disease. Malignant disease is not even a question anymore. We've been -- trials have been accepting this technology, and our goal in this webcast is to -- how to have the laparoscopic approach for these -- both techniques. The benefits of laparoscopic surgery, as anything, in minimally invasive surgery, with the smaller incision, less pain, less hospital stay, earlier return to activity,

2 and earlier return of bowel function. But we know that during this surgery, we have some risks, like anything else. You have risks with access, you have risks with electrocautery, with your vascular injuries, with your C02 insufflation, and enterotomies. So our goal today is going to go through different techniques for laparoscopic colectomy and try to minimize those that we know are present during this tech-- these laparoscopic colectomies. This is something that our patients come for, and you see their incisions, you know, why have a very large incision when you can have a left colectomy like this or a right colectomy -- you can see the size of the incisions. And this is something that the patients are -- going to be patient-driven. The patients are coming to us as professionals to perform laparoscopic colectomies, and we minimize when infections, hernias, bowel obstructions, et cetera, from the large incisions. Something that is totally patient driven in this age, and this shouldn't be a question today in But we've got some challenges, and today we estimate that less than 50% of all colectomies are done minimally invasive, and there's a steep learning curve. And I want to know -- as to explain to the audience, Gustavo, why do you think this is happening and -- and what can we do about it? 00:04:13 GUSTAVO PLASENCIA, MD, FACS: ell, in many -- in the early '90s, I mean, we thought that 80% of all the laparoscopic surgeries in the abdomen was going to be done via -- I mean, all the surgery was going to be done via laparoscopy, and as we can see, this hasn't happened. And it's a variety of factors. The steep learning curve and the fact that you really have to have a commitment to this surgery. Today, we have all the equipment. We have Harmonic scalpel, we have excellent trocars, we have things that can facilitate every surgeon to be able to do this surgery. And in spite of that, this hasn't occurred. I believe that now is when there's going to be another peak, another instance, that this is going to become a lot more popular. And we're going to be able to be doing these and seeing these more often than we have, especially after all these studies that have shown that we can do these for cancer and that is okay to do for cancer. 00:05:20 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: Can't agree more on that. I think today with the technology that we have, you know, us pioneers do, too. In the 1990s, there's a big advantage to start doing this technique in It's a different ball game than what you guys had before. But saying that, you know, one of our goals today is to give tips to our audience on how to perform this procedure by laparoscopic colectomy. And first we're going to start with the operating room setup with the patient positioned. We use NGTs or OGTs and Foleys. At least one surgeon and one assistant and one scrub technician. Two monitors at minimum. Better three or at least one that can be a satellite so you can move onto the floor up to the foot of the patient or the shoulder. You can use a colonoscope or a rigid sigmoidoscope when you're doing left colectomies. You have an energy source, you take the vessels and perform the dissection, and also you use ureteral stents selectively in different patients. This is how our O.R. setup is at Boca Raton, where you have ceiling-mounted monitors. That's the best way to have them, but you don't need this necessarily to perform the surgery. You can have satellite monitors on the floor, you can perform this procedure this way. But this is something that a lot of United States hospitals will have. Before getting into our technique, why don't we run a video showing the technology of a Harmonic Ace and how we can use this for our dissections and our vessel takedowns. Can you please run the video?

3 00:06:48 VIDEO NARRATOR: In the Harmonic system, an ultrasonic wave operating at a frequency of 55,500 cycles per second causes the active blade to vibrate, creating excursion of the blade tip from 50 microns at power level one to 100 microns at level five. The transducer, housed in the Harmonic hand piece, converts electrical energy to mechanical energy. It consists of a stack of piezoelectric ceramics sandwiched under high pressure between two metal cylinders. When pulsed with a high-voltage electrical signal from the generator at the resonant harmonic frequency of the ultrasound acoustic system of 55,500 hertz, the transducer, blade extender, and blade expand and contract with each wave length along the entire length of the device. Longitudinal expansion and contraction increases from just a few microns of longitudinal motion at the transducer to microns at the blade tip, where maximum motion occurs. 00:07:46 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: All right. Once we've seen how the technology works and what is the mechanics and the physics of this fabulous instrument, we're going to go ahead with the patient positioning. And the patient position is either supine or with the legs spread on the table or with the leg devices, depending on whether you're doing a right or a left colectomy. But one thing that is common is that you're going to have both arms tucked to the side and they need to be strapped down to the table really well. Moises, you've been doing this for many years, okay? Tell us your experience when you have a very obese patient, how important is this about the strapping the arms and strapping the patient to the table? 00:08:27 MOISES JACOBS, MD, FACS: Well, early on, before we realized how important it was, we've had patients who almost fell off the table. So we strap them in very tightly. We put tapes, we also use shoulder harnesses to keep them on the table. Especially with this kind of surgery, where you're putting patients in steep Trendelenburg or rotating them to the right or to the left, that's a very important point. And you can also see there in that slide the use of pneumatic stockings, which is something that is very important and should be mentioned. 00:08:52 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: Okay, so definitely prevention of DVTs between heparin and the amount of statins, we all do. And this is basically the third assistant during the surgery. You know, the table becomes the third assistant for our exposure of the target that we're going to go after. The technique, we can divide it in different bullets. And you can go from anatomy recognition to a identification of the pathology, mobilize the colon lateral medial or vice versa, depending on which technique you want. Vascular control you need to do, resection, and anastomosis. This is why maybe the colon surgery has so many steps that it becomes one of the -- on the learning curves, it comes all the way to the top. The surgical plan that we can follow is medial to lateral, lateral to medial, combination of both, or total mesorectal excision. I think it's very important -- and we're just going to say this at the beginning -- is you need to be comfortable with both procedures. You need to be able to -- because eventually they will merge at one point, and then you should be able to attack one or each side. Also need to know how to mobilize the rectum. That's one of the portions that's very important to stress that. The procedures that we're going to be talking today will be right colectomy,

4 left colectomy, and some tips for the low anterior section that we know there are some surgeons that are having problems placing the staples or dissecting the rectum. We're going to give them some tips how to do this. Let's start with the laparoscopic right colectomy. And in this case, you have two positions that you can do. You can have the patient totally supine and you can have the patient with the spread -- with the legs spread and the surgeon in the middle, like you're seeing on the video. Gustavo, you've been doing this for a long time, and I've seen your cases doing it supine. Do you think there's an advantage of it, or do you think it's just surgeon selection on how to do this positioning? 00:10:38 GUSTAVO PLASENCIA, MD, FACS: It is really very individual selection, because I think that we try to minimize the time that we have. We know that laparoscopic surgery takes a little longer, therefore we try to minimize the time that we -- and putting the patient in lithotomy takes a little longer, so our preference has always been just to put them in supine position. Now, having said that, when you have a polyp in the right colon and you want access to the right colon with a colonoscope, then many times we use the lithotomy position and we try to -- to do that for those particular patients. 00:11:19 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: So we can take out that it's the position of the patient will be the preference of the surgeon and which way he does on the table. In this case on the slide, you have the assistant on the left side and the surgeon in between the legs. And the monitors, it's right in front of where the target is, so there's a line between the surgeon, the pathology, and the monitor. Those are rules for minimally invasive surgery. And if you have other screens, that's perfectly okay. Now on trocar placement, everybody -- you look at a book and you see the trocars in different places. I think today we can accept that we can start with one trocar and then accommodate the trocars, but you can more or less know how many trocars you're going to use, and we agreed that mostly we would use four trocars to do this procedure. And in the slide, you're going to start seeing how the trocars are appearing. And the one in blue, it's a millimeter port, and the one that went from one side to the middle is a trocar that depends; if the patient is obese, we tend to go more towards the middle or if the patient is more a small kind of patient, we tend to be more liberal, more lateral, so we don't have the pathology right in front of us. Any advantages, Moises, of why -- what kind of scopes do we use, what size, and how many trocars and why is only one in the slide and the rest are 5? 00:12:37 MOISES JACOBS, MD, FACS: Well, I think as time has evolved, we use to use all trocars. And as we had experience, we realized that trocars give more discomfort and the instrumentation actually became more 5 millimeter oriented except for the staplers. So what we use today is three 5 millimeter trocars, as you see on the screen, and even the video, the optic, is a 30-millimeter five-degree scope -- I mean, a 5- millimeter 30-degree scope. And the only that we use is the stapler. 00:13:04 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: Okay, very good. So 5- millimeter trocars except for the stapler, we're using a 30-degree 5-millimeter scope. Then we go into medial to lateral, lateral to medial. In the slide, you can see a medial to

5 lateral approach. Any advantages, Gustavo, in going one way or the other? And how do you teach your residents, for example, your Fellow? 00:13:26 GUSTAVO PLASENCIA, MD, FACS: Well, the classic way that we have been doing the colon surgery in the open fashion, which is the way we started doing the colons, was from lateral to medial. And that has been for many years the way that we pretty much have used it. Now, it is important to know both ways, and we teach them, to the Fellows that we have, we teach them both ways, from medial to lateral. So you need to really, like you mentioned -- excuse me -- earlier, both techniques, medial to lateral and lateral to medial. And I think that's -- you have to be familiarized with both of them. 00:14:03 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: The one thing that we have to stress enough is that they have to know the anatomy one way or the other. In this case, you need to know where the ureter is, you need to know where the vessels are, and the duodenum and the pancreas. In the slide that you see, you see how the opening is a vascular control first, and then you proceed to the lateral approach. In the next slide is the lateral approach is starting in the lateral attachments and then go towards -- for the vascular control later. And again, I think it's very selective. It depends on the patient and what pathology you're seeing where you go one way or the other. And whatever is easier is what I think we choose to do. Let's go ahead and run the video for the right colectomy, and we're going to do some comments along the video. Let me start with this. This is just showing the pathology, where we -- it's a right colectomy. We're going to be placing a port in the left upper quadrant because the target is towards the right, and that port should be constant. And then the rest will be accommodated depending on what we see after the port. Here the four trocar placements, as we saw on the first slide. And in this case, a patient is having a right colon cancer. As you can see, the patient is quite obese, and this time we decided to go lateral to medial, since we were having some trouble lifting up the mesentery at the beginning from the medial side. Just showing this so you can see from the lateral space, you have to be between the kidney and the colon. You don't want to fall too lateral on the side. So we'll be -- we'll go behind the kidney. Moises, in this dissection, when do you look for the ureter in this case, for example? Do you always look for the ureter on the right side, or is it something that you do only in selective cases? 00:15:48 MOISES JACOBS, MD, FACS: We -- we do it in selective cases. But when I'm not sure of the anatomy, when I'm not sure where the gonadal vessels are, when I'm not sure if I'm in the correct plane, I look for the ureter before I fire any staplers or use the Harmonic in the area, because obviously you don't want to injure the ureter. And that's worked well for us. And you usually do it medially, from the medial aspect of the mesentery where I enter. 00:16:11 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: Yeah, couldn't agree more with that. And in any certainty, you have to look for the -- for the structures before you do any transection. 00:16:19 MOISES JACOBS, MD, FACS: You also need to identify the duodenum medially so you stay above that and make sure that you don't injure the --

6 00:16:23 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: That's correct. This is the -- what you're seeing on the video right now is you can see that the Harmonic Ace is being done by the surgeon on the left side of the patient. And in this case, it's the takedown with the lateral approach. That's the duodenum behind the Harmonic, and we're taking the attachments to be able to be able to free that completely. And then seeing what our plane is, you can see the gall bladder, the duodenum, the kidney is behind it, and the plane is very well defined. In that case, we didn't have to go and look for the ureter since everything was in the right plane. Then we go ahead for the vessels. What do you do today for the vessels, Gustavo? Do you use the Harmonic technology? Do you use staplers, do you use clips? Whatever you -- what have you been using in the last year, for example? 00:17:07 GUSTAVO PLASENCIA, MD, FACS: We use a combination of -- of techniques. The -- most commonly, it's either the Harmonic or use the stapler. And that's -- 00:17:22 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: Here in the video -- let me interrupt you for a second -- there was a little branch that we -- by traction. And that was our fault. There's a bleeder on the side from one of the vessels, and this is the way -- we wanted to show this just to show when you're in trouble that you can use an endoloop to be able to control that right at the base. So that was a technique issued from us making a little more traction than we were supposed to. And then cleaning the rest, you can see the duodenum down in that area. Going back to the Harmonic, if we -- it's a combination, but 90% or more of our colon resections these days are used -- completing in that transection of the vessels with the Harmonic scalpel. And we have taken pretty much every vessel around the colon with this technology and so far it has been working for us. And this part of the video is dissecting towards the terminal ileum, and I can strengthen this enough -- and I'm going to ask Moises: why are we doing this intracorporally? Why are we transecting everything inside? 00:18:19 MOISES JACOBS, MD, FACS: Well, we get better mobilization that way. We'll have the small bowel -- basically the colon reached the abdominal wall much, much easier, which also lets us make smaller incisions. And when you pull out the intestines, you can pull one out at a time, which makes the incisions a little smaller. And obviously smaller incisions create less pain for patients. 00:18:37 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: In this video, after transecting the terminal ileum, you saw that I placed an endoloop there, and I learned that trick from Dr. Plasencia when I was a resident, and so I can -- in a fatty patient like this, I can easily fine this -- both structures without spending any time. Now, once we have everything mobilized and you can see me grabbing that -- the suture there, then we're ready to see where we're going to exteriorize. And we exteriorize where -- usually can use one of the trocars or you can go toward the midline. It depends what's easier, what reaches better for the patient. In this case, it's towards the midline. And using the Echelon again to transect the transverse colon, bringing up the terminal ileum. We align them with the 3-0 silks and then before we fire this, it's very important to check the alignment of the mesentery. And,

7 Moises, what do you do for that? Do you look inside again or how do you make sure the alignment is well performed? 00:19:34 MOISES JACOBS, MD, FACS: You have to look inside again, because we twist it as you take it out. That's very important. 00:19:38 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: I agree. Within there, we have some twists, so definitely we check before we do any stapling, firing. And then we're closing with the TA. And even though we'll check again after it's been fired, you're going to see in a minute in the video that once this is accomplished, then we'll look inside again. And it's very important, because once you transect inside, you can twist the mesentery. And here's checking out to make sure that the mesentery's well aligned. Gustavo, do you close the mesenteries on the right colon, or do you leave them open? Do you do that only for the open cases or not? 00:20:014 GUSTAVO PLASENCIA, MD, FACS: We used to do it in open surgery. Now in laparoscopic surgery, in the early days especially, and we didn't do it -- we didn't think that it was very important. We don't do it today, so today we leave it open even in open surgery when we occasionally do some open cases. So for the most part we leave it open. We haven't had any real big problems with that. 00:20:38 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: Most other surgeons would agree with that. If the defect is very wide, we don't close those defects. On the video, you'll see that the incision is about two and a half centimeters, and that's the advantage of resecting everything inside. Let's -- 00:20:53 GUSTAVO PLASENCIA, MD, FACS: It's important to mention also the wound protector for the cancer patients. And that also gives you a little bit more of a wider opening when you place a wound protector in distraction side, that it helps you, you know, do just like a two and a half centimeter incision like they're showing. 00:21:12 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: Okay, a wound protector definitely for oncological surgeries. It's a must, it has to be. It's a must, you've got to use it. It also helps you widen it, but it hasn't been proven to decrease infections. But we use it for benign or malignant. Moises, in the screen you'll see the intracorporeal anastomosis. That's been advocated by Morris Franklin for a long time, and I think it's part of his routine technique. Which patient do you think will have a benefit of this technique and when will you use it? 00:21:42 MOISES JACOBS, MD, FACS: I think obese patients, where it's difficult for that colon to reach into your abdominal wall, especially in thick abdominal walls, it's a tremendous technique. It facilitates anastomosis and it's really faster sometimes and less traumatic for the patient. Also when the transverse colon cannot be mobilized or you haven't mobilized it enough, then you have to do that technique intracorporeally. 00:22:04

8 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: Very good. Let's go into laparoscopic left colectomy. And the patient position on this time, arms will be stuck to the sides, the legs will be all the way spread open, and then you have to decide where the monitors are going to go, and you have two at the feet, one on the right, one on the left, and if you have three, you put one on the left shoulder in case you need to mobilize the splenic flexures. If not, you can mobilize one of the satellites. It's important that in this part we have a colonoscope in the room available. If you don't, you need a rigid -- because you may need to test the anastomosis if you go lower. And most of the surgeries will be done with the surgeon on the left -- with the surgeon on the right of the patient and the assistant on the left. In some places that we do it backwards with surgeon on the left, the assistant on the right. the important part is whoever gets the right -- in the right plane, then they should switch back and forth to be able to have, you know, this -- this surgery in synchronization. The trocar placement for the left will be more or less in this pattern, and you'll have one and the other one will be 5. And the lower you get, you tend to put the trocars a little bit lower. Anything, Gustavo, about your trocar placement on the left side? Does it look anything familiar to what we have on the screen or is it a little bit different? 00:23:27 GUSTAVO PLASENCIA, MD, FACS: Maybe a little bit different in the right upper quadrant trocar there that we usually have it in the left upper quadrant and that's where we use the camera to have the alignment into the left side of the colon in the pelvic area, kind of in alignment with the camera, so that's maybe the only difference for the most part. It's pretty much the same. 00:23:49 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: So 30 degree scope, only one 10-12, the rest are 5-millimeter ports. Then we go through the same decision of medial to lateral, lateral to medial. And I'm going to go fast through the slides because it's the same thing on the right side, but here the main concern is ileac vessels and ureter, where they are. So if you start from the lateral side, this will be your exposure. Once you've finished with that and you if you do a lot of mobilization, you should always go to the line of Toldt all the way up. The dissection of the splenic flexure, you usually can do it between the legs and you can go align that area to be able to do that. And the same thing becomes after you detach that. We do selective mobilization of the splenic flexure depending on what procedure, unless it's for oncological purposes. Otherwise if it reaches down or you're not doing a true left colectomy, if you have redundant colon, you can leave that alone. Now, if you're doing medial to lateral, you can also go in that direction right at the root of the mesentery and right on top of the promontory, and then you can get to the same exposure that you have from lateral to medial to be able to have the ileacs and the ureter exposed as well, and you can also do a medial mobilization of the splenic flexure. Let's do a video of the left colectomy. Now, this is a patient who -- a male who had five episodes of recurring diverticulitis with one abscess being drained before. He was cooled off and then he came for surgery. This patient in this case, we had a stent in place and we decided to start lateral because there were some holdings on the -- to be able to traction this all the way up because of the redundancy. Do you use ureteral stents, Moises, on your cases? 00:25:37

9 MOISES JACOBS, MD, FACS: We use them selectively. You know, in a patient who had multiple operations before, like this gentleman, with a lot of abscess formation, big masses, we use ureters -- you know, rectal tumors that are fairly large, we use stents. But we mostly -- mostly we don't, except in those cases. 00:25:56 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: I agree. Here we're seeing how we're going -- the surgeon from the left side is approaching the base of the mesentery through -- from the left upper quadrant trocar, and you can see how the Harmonic can run parallel like the same concept on the medial to lateral dissection on the right colon. And on this side, we take of the peritoneum of the mesentery and we identify the ureter from the medial side. You're going to see it in a minute. We won't take any vessels before we identify the ureter. You're going to see it has been already identified. You're going to see it after I take this. But the rule is you don't take any vessels before you see the ureter. And here you're seeing how we're taking an artery. You see how the left hand approaches the - - the left hand approaches the tissue so the Harmonic can work and get a good sealing. And the light that you see there is the ureter being shown that it's been already dissected earlier before we transected the vessels. Again, you can see the tension of the tissue is being decreased to let the Harmonic work, and I think this is a key in this technology. And then you can see how it's been -- the vein is being taken. Again, this is a benign disease, we're not doing an oncological resection. We'll try to save as many vessels as we can, but this has to be taken with the segment. You're going to see how close -- and this is -- this is a very important part to get the ureter visualized as well as the vessels, because there's been severe complications from not being thorough. And this dissection, you can see how close it is and you can see the light there at the end with the vessels also. You can see the ileac vessels showing below this. This is how it looks from the lateral side. And if you do your dissection medial to lateral and you do your homework from there, it should be very easy to go into this area and then just take the Harmonic scalpel, and then once you open the window, you should be able to bring this all the way down through the space that you already dissected medially and you have to go in the upper rectum. Gustavo, how important is it that your dissection goes into the rectum and why do we do that all the time? 00:27:58 GUSTAVO PLASENCIA, MD, FACS: Well, for diverticular disease -- and I've actually seen some cases that -- presentations that I've done even on TV, it's important to transect at the level of the rectum. Even if there is no disease in the distal sigmoid, the transection should always be the rectum because the recurrence rate is a lot less that way, so 00:28:21 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: We agree. Here we are seeing a 60-millimeter blue cartridge Echelon stapler coming from the right lower quadrant port. And you can see visualizing there's nothing catching on the other side. That's very important. There's no ureters, nothing in there, it's being completely across the rectum and then we've been firing. One of the advantages is 60-millimeter and a wide amplitude of the jaws of the stapler. And as you can see, it's pretty much across completely, just a little piece of fat is being transected at this time. And that's the upper portion of the rectum being there. Now, you can see how much redundancy is here, and I'm checking to see if I don't need any further mobilization. And once I decided that, then using the

10 wound protector, we exteriorize the piece and we do -- we place the ampule (sp?) on the outside. What size ampule do you usually use, Moises? And why do you use this technique? 00:29:11 MOISES JACOBS, MD, FACS: Almost always we use the 29 ampule. 00:29:15 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: Mention the transection. 00:29:16 MOISES JACOBS, MD, FACS: The reason is because it's -- you know, it's wide enough that it's easily useable and it easily passes through the anus and through the rectum. 00:29:25 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: The proximal transection is where the bowel is pliable and it's soft and there's no more disease. And we're using here a reusable purse-string device by placing a 2-0 nylon suture and then placing the Allen bowl inside. And once we do that, that's the transection. The resection is from where it's pliable to the top of the rectum, then just by turning the device of the wound protector, we can insufflate immediately and then we can go ahead and perform the anastomosis. Gustavo, any -- what do you prefer to do your anastomosis? Like you're seeing it here and like a side to end, or do you always do end to end anastomosis? Is there any difference in doing this type of anastomosis versus another one? 00:30:13 GUSTAVO PLASENCIA, MD, FACS: In general, what we prefer is to do the end to end, because you want to have the flexibility of anastomosis without tension. Now, if you have an excess colon, you could use this Baker type of technique, but for the most part, we use the end to end because that gives you enough -- just to have no tension in the anastomosis. So if you have an extra colon distally, which normally you don't have much because of the nature of the resections that you're doing, then you can do a Baker like here. 00:30:49 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: Very important here that you don't trap anything when you close the stapler. Very important to have the mesentery aligned well and the tinea, and then very important to check your anastomosis at the end like we're doing at this time with a colonoscope during the water test maneuver. And this is pretty much a sigmoid colectomy on this patient. Let's go ahead and go back to our presentation slide. One of the things that, since we're rolling, we close all the trocars with a suture passer. And we have seen trocar hernias, and even in -- we use a suture passer because we are for sure that we are getting both sides of the fascia. You can see the incision size in this patient after diverticulitis. This incision is barely two and a half centimeters in size, and it's right on the umbilicus. You can see it right there. So this patient will definitely benefit from this type of procedure. This patient went home in two or three days. Let's go into rectal cancer. And you know, TME has been popularized by Dr. Heald in 1988, and this has been a discussion if laparoscopically we can do the same dissection or not. And right now, we know that laparoscopically with the exposure that we have, we can do even an equal or better dissection than the open technique. And we also know that the risk of local recurrences correlate with the quality of the excision. So my quality is very good. That's why I'm looking forward. Some tips about rectal

11 approach, and I just want to tell the audience there's a sequence on this that works pretty well for all of us. And we see the rectum as a house. And the dissection starts from the floor. So we go posteriorly first. And then we take the walls. And once you do posteriorly, you can go on each side and take each wall and then we approach the anterior wall. So we're going ahead and see some videos of this approach. And so how -- how are we starting the posterior approach? And here you can use the Harmonic scalpel. You're going to see it going posteriorly first and getting into the hollow -- very hollow plane to be able to get into the posterior approach. And once you get posteriorly in the presacral space, then -- then once you get that, then you'll still be able to use cautery or the Harmonic, and both are accepted. You just have to know about the thermal spread once you go posteriorly that you have to be careful with, but if you get into the right plane, you should be in an avascular plane. And you can go all the way down with either instrument, all the way down to the elevators of the patient. Now, what does this technique work is your left hand. Your left hand of your assistant has to make this tissue go all the way up anteriorly to be able to expose the tissue that you have. And these days we do most likely will do this with the Harmonic scalpel. And this is just showing after you do the posterior approach that you can go to the walls of the house that we're talking about, you can go laterally and then you can easily go into the -- all the way down until the level that you would like to be transected as. And then getting this, you can go the left side first and then you can also do the right side that we're going to see in a minute. And again, you can see how the traction is what does the exposure of the tissues, so your assistant and as well as your left hand -- if you are right-handed, it should be as good as your right hand to be able to do this. Because here you've done already the posterior part, you've already done the -- the lateral walls. We're going to see in a minute the anterior approach, but we've got some questions here from -- from our -- from the internet. And one of the questions here, Moises, is: can this procedure be used for abdominal perineal cases in cancer? 00:35:00 MOISES JACOBS, MD, FACS: Absolutely. In fact, it's ideal for abdominal perineal cases in cancer, because you can -- with a scope you can see much, much better into the rectum, into the pelvis -- into the area of the rectum and the pelvis than you can with your eye. And you know, when you're doing open surgery, you're blindly moving these things. With laparoscopy, you're doing it under direct vision via the scope. And the only part that you have left to do then is removal of the anus, and that's done, you know, from the outside. So you just create the colostomy without any incisions. 00:35:28 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: You know, a lot of surgeons will say you should first attack an abdominal perineal and then a lower anterior section. Because you don't have an anastomosis, you can go as slow as you can, and then you can go from the other side. 00:35:41 MOISES JACOBS, MD, FACS: It's a safer procedure than the lower anterior section. 00:35:43 GUSTAVO PLASENCIA, MD, FACS: I think it's important that -- that even though you have access to the perineum that you should do the dissection exactly how you do it in open surgery. That is, it's circumferential, TME dissection all the way down to the elevators, which is easier to do l laparoscopically because you can see better. But don't

12 compromise. Don't think that if -- because you have perineal access that you should just do it to a pelvic inlet, because then you're going to have a hard time. 00:36:11 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: Couldn't agree more. Let's go to our next video just to show the anterior portion of the dissection. And how important it is to identify it. In this case it's a female. And to know where the plane is, how to avoid getting into the vagina. Can you run the tape, please? And here it's just showing with a finger in the vagina to show the vicinity of the -- of the rectum with the vagina. And if you can see in the video, if if you can see the dissection in the video, once you do the lateral approach and the posterior approach, it's easier to get into the anterior part of the area. Let's -- before we're going to run the next video, we have another question. Our next video will be the staplers insertion, but we've got another question from the audience. And Gustavo: any preference of energy sources used for the pedicle division of the vessels? Do you always use one technique, do you use two sealings with the Harmonic, do you just go one? What is your technique of preference? 00:37:16 GUSTAVO PLASENCIA, MD, FACS: Okay. In -- my preference is to use the Harmonic scalpel unless I see that there is a very large vessel and we know that we have some limitations. But the majority of the vessels in the colon are not larger than five millimeters, which we can easily take with the Harmonic. Sometimes, occasionally, you will see a larger vessel, and then we normally will use a stapler in that case. As far as using the Harmonic, we usually use a one-level technique. We don't go up and down because we don't think that it's necessary and it's probably a waste of time. So, yes, onelevel transection. 00:37:56 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: Yeah, I think a lot of it has to be common sense. You know, we don't -- there's nothing that's 100%, so once you take it, if you can get it at one level and it's good, we leave it alone. If it's something that's no good, we sometimes do another application. That's something that's a surgeon selection. 00:38:12 GUSTAVO PLASENCIA, MD, FACS: I should have just elaborated a little bit more on that, that any time that we're taking a vessel independently, what method we are using, we are prepared to control that vessel. So the assistant is ready or your other hand that is not doing the -- the cutting or the stapling is ready that if there was any bleeding that were to occur, you immediately control it, and I think that's important. So we're really on top of things. 00:38:39 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: Yeah, one of the reasons why I think the blood loss in laparoscopic colectomies is the detail surgery that we perform laparoscopically -- 00:38:46 GUSTAVO PLASENCIA, MD, FACS: It's less. EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: It's less. And we know that the average, and we can -- most of the surgeons would agree that it's less than 50cc's during the whole procedure if we do the procedure right. Let's see what -- a lot of the surgeons having trouble placing the staplers down in the pelvis in the male, we've got two clips

13 showing two versions. One is going form the lateral side, from the right lower quadrant port. And then what's the difference moving the port towards the superpubic and getting in the anterior. Are we ready for the next video from the lateral approach, please? Here's coming from the left side. And you can see the colonoscopy doing that at the same time, and I think that is important where you can see where you're closing the stapler. And your distal margins will be always good. You're not guessing where it is in a narrow pelvis, you're seeing exactly where the stapler's being closed, and in that case, you can see exactly, you know, knowing that your margins are going to be good. Now, that's from the lateral side. Sometimes we've got trouble getting in that. You've got a 60-millimeter stapler and we're going to see in a minute how you can use it from the anterior approach. Any tips, Moises, for this type of resection with the staplers? 00:39:52 MOISES JACOBS, MD, FACS: If you go very low, you need to transect very lowly. I mean, sometimes a stapler has -- you need an angle stapler, which we have, a 60- millimeter angle now. But before we had that, we would have to take several firings, either two or three firings, and also push up on the perineum and push the rectum up from the perineum so it would bring it up and make it easier to fire. 00:40:12 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: I think that's a very important point. A lot of the surgeons forget that just by pushing, you have an assistant or a nurse pushing from the bottom of the patient the perineum up, you can get an inch, you can get a few centimeters, to allow the stapler to go down into that area. You're going to see one example of that -- are we ready for the next tape? Okay, we're going to be ready in a minute? 00:40:39 GUSTAVO PLASENCIA, MD, FACS: One other technique that could be used occasionally with especially colo-anus is to transect above and do a rectal aversion of the stump that is left and then you can see exactly the margin that -- that you use. And occasionally we use that technique as well. 00:40:55 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: That's a very important point. Here we're going to see how the stapler's being moved to a superpubic trocar. And you can see how this approach is totally anterior to the rectum, a step from the side. And here you're using the longitudinal dimension of the pelvis to be able to do that portion. Now here is, by several firings, we're able to go all the way down and you're going to see how, after that, the staple line is complete, a total mesorectal excision. There you can see it's shiny. And you can see how low we are in this stapler, using the 60-millimeter. We're all the way down pretty much you can see the elevators there. So you can go as low -- you can do a pouch after that, and that's as low as it gets. All right, why don't we finalize this tape and let's continue with this. Well, in -- we've got some questions here for the audience. Moises, what advantages does Harmonic offer specifically in your patient population? You think you're faster, you think you're getting -- what is it -- why are you using this technology for in your laparoscopic colectomies? 00:42:02 MOISES JACOBS, MD, FACS: It's definitely faster. You know, you're using -- it's dissecting and cutting and ligating all in the same steps instead of, you know, taking a

14 clip and putting -- and taking scissors and putting another clip and cutting in between. All that takes time. This is one continuous flow movement, and I think it's much faster. 00:42:20 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: I think one thing here, Moises, to interrupt you, before when we were doing benign disease for, let's say, a sigmoid colon, you know, we were going down all the way to the roots because we didn't want to go through a lot of vessels. Here now with this technology, you can go stay -- if it's a benign disease, you can stay right on top. It doesn't matter how many vessels you're taking, you're just going through and you're speeding up your procedure. 00:42:42 MOISES JACOBS, MD, FACS: In that right colectomy tape, you took the whole right -- you know, the mesentery, the small bowel using -- 00:42:46 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: We did it that way. Gustavo, everybody's talking about nodes and robotic surgery. What do you think is the future? Are we heading into that direction? What do you recommend to the new surgeons who are starting to do this procedure and where do you think we're going? 00:43:05 GUSTAVO PLASENCIA, MD, FACS: Well, I think we're going in the right direction, to tell you the truth. And I -- if I were now to be a young surgeon, definitely robotics and nodes would be my first agenda. But if you are looking at 15, 20% of adoption of laparoscopic surgery, since Moises he first described the first colon resection, it's been 18 years. And we still have, I think, a lot of room to grow in the laparoscopic arena. So definitely robotics and nodes is -- and I still even at my age think that, you know -- some of this is tough. And our friend Morris Franklin has done a lot of work and actually was probably one of the first pioneers, taking specimens out through transecting the rectum, and he did that in the early '90s, too, so I think that's the way of the future and is going to happen. 00:44:04 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: I think one of the -- something that we have to strength out is that for 18 years, the education in laparoscopic colons, we think there's a lot of deficiencies there. And we all three and with Morris and a lot of other surgeons from the United States and around the world, we've been working on a module to be able to see how we can teach this better, see how they can adopt better this technique, and I think this next year for us and this year inclusively we'll be having a lot of exciting learning capabilities and teaching to other surgeons, and we're going to see this in the future. Let me -- in summary, we can say that after seeing this demonstration that I think that laparoscopic colectomy is feasible. We can say that. We know it's safe performed by the right surgeons. We've got to be trained on that. It's an advanced procedure, it's not -- a laparoscopic colectomy is something that is much more towards the end of the -- of the line. But it offers maximum early recovery, and we do this for our patients to recover early and have better results. So it's nothing that -- we all agree on that. Is it technically feasible? Yes. Is it safe? Yes. And is there quality of life benefits? Yes. There's some other questions coming from the internet that we'll be happy to answer. And Moises, this is: what is the risk of malignancy spread or recurrence with Harmonic technique or realization of cancer cells? Is there any of that?

15 00:45:40 MOISES JACOBS, MD, FACS: I think that that's been proven thoroughly by various prospective randomized studies that laparoscopic surgery for the colon for cancer is probably better as far as oncological results than open surgery. And I don't mean that in a bad way, I mean that it's less pain and faster recovery but the same oncological results. I mean, it's the same. It's no different. 00:46:10 GUSTAVO PLASENCIA, MD, FACS: If you're doing the same operation, you should have the same results. Except that if you're doing the same operation and you're minimally invasive, immunologically, we know that we are much better preserved and therefore that may in the future show some advantage to the laparoscopic approach. So it may be an indication if you have a cancer to do it laparoscopically because you're going to show an added benefit to the procedure. 00:46:38 MOISES JACOBS, MD, FACS: But I don't think that's a question today. 00:46:40 GUSTAVO PLASENCIA, MD, FACS: It is not, but you know. 00:46:41 MOISES JACOBS, MD, FACS: I don't think it matters whether you use cautery, whether you use Harmonic. It just doesn't matter, I don't think. I think it's all surgeon-dependent, too. 00:46:49 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: I agree. GUSTAVO PLASENCIA, MD, FACS: I agree. 00:46:50 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: Well, we're almost at the end of here. I just want to ask you if you have any other comments for our audience or any advice regarding this technique? Moises, if you wan to add something that we -- 00:47:04 MOISES JACOBS, MD, FACS: I think this is -- you know, this technique is more difficult because it involves all four quadrants. It's not just like a gall bladder, it's localized in the right upper quadrant. You mentioned a little while ago, it involves stapling, mobilization, anastomosis, all various things that we do in surgery that we don't do in many other operations. I think morbid obesity, the benefits for laparoscopy have brought about more and more interest in minimally invasive surgery, and that's going to make more and more surgeons approach this laparoscopically. And I think it's the wave of the future which has been here now 15, 20 years and still hasn't caught on. But I think it's going to catch on fairly soon now. 00:47:44 EDUARDO PARRA-DAVILA, MD, FACS, FASCRS: Gustavo? 00:47:46 GUSTAVO PLASENCIA, MD, FACS: I think that this is here to stay. It's not going to go away. Therefore, the young surgeons out there, adopt this the sooner the better because this is not going to disappear. This is going to go in another direction and it's just going to be the direction of more procedures that are going to be done. 00:48:05